Assessment Form Post Polio Syndrome and Late Effects of Polio
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1 FULL NAME: DATE OF BIRTH: PHONE NUMBER: CURRENT HOME ADDRESS: ADDRESS: THERAPIST: REFERRAL SOURCE: CURRENT GP: NEXT OF KIN: ACC/NHI NUMBER: PATIENT GOALS OF TODAY S ASSESSMENT: MAIN PROBLEMS PATIENT BELIEVES COULD BE ASSOCIATED WITH POLIO / LEOP OR PPS: Current Issues and/or Impairments How many years of stability? What has changed in recent years? PRESENTING CONCERNS: New Weakness Increased Falls Fatigue Functional Ability Pain Sleep Breathing Swallowing Continence Weight Changes PLEASE DESCRIBE FURTHER: 1
2 Current Functional Ability and Social History Mobility and ADL s: Current exercise regime: Work and lifetime activity: Family support and networks: Other health professionals, alternative RX and noted benefits: Difficulty breathing and/or swallowing? Any investigations? Fatigue including sleep regime: Falls history: 2
3 Body Chart Pain Chart 0 2 No Pain Mild Pain 4 6 Moderate Pain Severe Pain 8 10 Very Severe Pain Worst Pain Possible Observation? E.g. Pain, tone etc. Intermittent or Constant? Describe Aggs Eases?/10 General Observation: Atrophy Trunk Alignment Joint Laxity 3
4 Leg Length - Measure in Supine: TRUE LEG LENGTH: (Greater Trochanter to Medial Malleolus) APPARENT LEG LENGTH: (Umbilicus to Medial Malleolus) Right: Left: Right: Left: Muscle Chart - Upper Limb RIGHT LEFT UPPER LIMB POWER /5 and ROM Comments POWER /5 and ROM Comments Fatigability - Joint Laxity repeated tests Shoulder Flexion /5 /5 Abduction /5 /5 Adduction /5 /5 Int. Rotation add /5 /5 Ext. Rotation add /5 /5 Int. Rotation 90 abd /5 /5 Ext. Rotation 90 abd /5 /5 Scapula Elevation /5 /5 Depression /5 /5 Protraction /5 /5 Retraction /5 /5 Elbow Flexion /5 /5 Wrist Supination /5 /5 Pronation /5 /5 Flexion /5 /5 Ulnar Deviation /5 /5 Radial Deviation /5 /5 Fingers Flexion /5 /5 Lumbricals /5 /5 Thumb Flexion /5 /5 Abduction /5 /5 Adduction /5 /5 Opposition /5 /5 4
5 Muscle Chart - Lower Limb RIGHT LEFT LOWER LIMB POWER /5 and ROM Comments POWER /5 and ROM Comments Fatigability - Joint Laxity repeated tests Hip Flexion /5 /5 Abduction /5 /5 Adduction /5 /5 Int. Rotation 0 /5 /5 Ext. Rotation 0 /5 /5 Int. Rotation 90 Flex. /5 /5 Ext. Rotation 90 Flex. /5 /5 Knee Flexion /5 /5 Ankle Dorsiflexion /5 /5 Plantarflexion /5 /5 Inversion /5 /5 Eversion /5 /5 Toes Flexion /5 /5 Lumbricals /5 /5 Trunk Flexion /5 /5 Lateral Flexion R /5 /5 Lateral Flexion L /5 /5 Neck Flexion /5 /5 Side Flexion R/L /5 /5 Rotation R/L /5 /5 5
6 Functional Objective Assessment Bed mobility: Sitting and standing posture: Transfers from sit to stand on and off floor: Standing balance, stairs, dynamic balance: Gait Assessment Swing Phase Stance Phase Trunk Hip Knee Ankle Consent for Obtaining Media Outcome Measures Mini-Bestest: 6 or 2 Minute walk test: Timed up & go (TUAG): 10 Metre walk test: 30 Second sit to stand: Piper fatigue scale and SF-36: Dynamometry: Activity, balance and confidence scale: Sensation Light touch P and N Chart needed Y/N Proprioception UL Thumb intact/impaired LL Big toe intact/impaired 6
7 Rehabilitation Plan - In Summary This is the part we do together as a tool for change not just an outcome measure but a plan to empower and increase awareness of own situation needs and goals. See the possibilities and also accept the responsibility. What are the difficulties? E.g. impairments and resultant activity/ participation limitations. What is it that you want to be able to do better? PROVIDED EDUCATION / RESOURCES: Fatigue management Education on adapting the environment Education on exercise benefits/risks Exercise prescription provided How can you implement these strategies? What might you need to change about your environment? About your pace? What could you limit that would have a positive impact? What do you think you could add that would help your overall wellbeing? ONWARD REFERRALS - PLEASE TICK WHICH APPLIES: Lab Studies Imaging Electrodiagnostic Studies Pulmonary Function Studies PT Orthotics OT Sleep Studies Consultant Other 7
8 TREATMENT: ANALYSIS: PLAN: REVIEW: Signed: Therapist Name: Date: 8
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